While the teams that would form the National Football Conference struggled to agree on a realignment proposal, the AFC teams quickly found an alignment. The Oilers, who were part of the AFL East before the merger simply because it was further east than the Kansas City Chiefs, were placed in the AFC Central with the Bengals, Browns, and Steelers, being the only team in the division that wasn't in or near Ohio. The Oilers were placed in the division at the insistence of Dan Rooney, much to the chagrin of Al Davis.[1] The Oilers and Steelers became acquainted with each other right away, when the two teams met in the season opener of the 1970 NFL season in Pittsburgh, a 19-7 Oilers victory in the first-ever NFL game at Three Rivers Stadium. The two teams met again four weeks later at the Astrodome in Houston, a 7-3 Steelers victory. The opening season win would be the only time the Oilers would be ahead in the overall series; the series would be tied again in 1971, but since then the Steelers have had the overall series lead, currently at 42-31 in the regular season. At 77 meetings overall, the Oilers/Titans franchise has played the Steelers more than any other team in its history.[2]

The rivalry didn't initially pick up steam, as the Steelers were starting to become a powerhouse in the NFL during the 1970s while the Oilers collapsed completely. However, the Oilers became a contender in the latter part of the decade and challenged the Steelers to division and conference supremacy. Unlike other rivalries such as the one between the Steelers and Browns that was based on the close proximity between the two teams and was more fan-driven, the rivalry between the Steelers and the Oilers/Titans franchise was driven on personal hatred between the two teams, much like the concurrent rivalry the Steelers had with the Oakland Raiders or the rivalry with the Baltimore Ravens decades later.

The two teams met in the AFC Championship Game two years in a row at Three Rivers Stadium, with the Steelers dominating the "Luv Ya Blue" Oilers 34-5. The Steelers were expecting a closer encounter in the 1979 AFC Championship Game, which was marred by a controversial call in the third quarter when quarterback Dan Pastorini threw a pass to wide receiver Mike Renfro in the end zone. It was ruled incomplete, despite television replays clearly showing Renfro having possession of the ball with both feet in the end zone; even Steelers radio commentator Myron Cope thought it was a touchdown. The Oilers had to settle for a field goal, and the Steelers would go on to win 27-13; the game itself would spark the debate on whether or not the NFL should have instant replay, which would go into effect for the 1986 NFL season.

Both teams hit hard times once the 1980s hit, with the Oilers quickly sinking to the bottom of the division and the Steelers hit with the retirement of several key players from the dynasty years, only remaining competitive due to the AFC Central as a whole being weak during this time. By 1987, the Oilers began to have sustained playoff appearances again under quarterback Warren Moon and controversial coach Jerry Glanville while the Steelers were still rebuilding from their mid-1980s dropoff.

However, the two teams would clinch a wild card spot in the playoffs in 1989, the only year Chuck Noll would win NFL Coach of the Year. During a regular season matchup in Pittsburgh earlier in the year, following the game the usually stoic Noll in post game handshake grabbed Glanville and told him he'd better watch out or he'd get jumped on. This was in reaction to Glanville's earlier comments on how the Oilers field was the 'house of pain' and his prediction that his players would intentionally hurt the Steelers; bounties are now outlawed in the NFL. In the Wild Card round, the Steelers, despite having been swept by the Oilers in the regular season, defeated the Oilers in overtime 26-23. Glanville would be fired from the Oilers after the game.

The Oilers were the class of the division for the early 1990s, winning two division championships, while the Steelers were slowly becoming a threat again under head coach Bill Cowher. The two would exchange division titles in 1992 and 1993 before the Steelers became the dominant team in the AFC Central due to Oilers owner Bud Adams going through with his threats to blow up the team and rebuild if it didn't go to the Super Bowl.

During this time, both teams were fighting for new stadiums in order to remain competitive. While the Steelers would eventually get one in Heinz Field (although they would've stayed in a refurbished Three Rivers Stadium if the financing plan for Heinz Field fell though),[3] the Oilers couldn't get a new stadium built in Houston and announced they were moving to Nashville for the 1998 NFL season. The Steelers (along with the Bengals) were one of six teams to vote against the proposal out of respect to Houston fans due to the rivalry as well as having recently encountered similar issues with the Browns.[4] The Oilers ended up moving to Tennessee for the 1997 season instead due to lame duck status in Houston; Houston would receive a new NFL team in 2002 when the Houston Texans started play.

Due to the size of Vanderbilt Stadium in Nashville (only 41,000 seats), the now-Tennessee Oilers decided to play at the Liberty Bowl Memorial Stadium in Memphis as an interim home until what would become LP Field was ready to open in 1999. Ironically, most of the crowds in Memphis were more than small enough that Vanderbilt Stadium would've been able to accommodate them. Despite that, the Oilers were planning on playing there again for 1998. That changed after the final game of the season, when the Oilers faced the Steelers in front of 50,677 fans—the only crowd that could not have been reasonably accommodated at Vanderbilt. However, Steeler fans made up the great majority of the crowd (at least three-fourths, by one estimate [1]), despite the fact that it was a meaningless game for both teams (the Steelers already clinched the AFC Central and a first-round bye in the playoffs, Oilers were already eliminated from the playoffs) and the Steelers were resting several starters. The Oilers won 16-6 against mostly Steelers backup players. Adams was so embarrassed that he abandoned plans to play the 1998 season in Memphis and ended up moving to Vanderbilt after all. Adams would rename the team the Titans in 1999 when Adelphia Coliseum (now LP Field) opened.

The NFL realigned its teams for the 2002 season, placing the Titans in the new AFC South while the Steelers remained in the now-renamed AFC North. Although the two teams wanted to remain together in the same division,[1] they were not able to because the Titans' vote was controlled by the NFL since it recently relocated while the Steelers (along with the Bengals) were required to remain in the same division with the Browns as a result of the NFL's settlement with the city of Cleveland in 1996.[5] Additionally, there was some sentiment to keep the Ravens in the same division as the Steelers, although at least one realignment proposal did have the Titans in the AFC North.[5] Despite that, the Steelers and Titans have still played each other rather frequently, having only not played each other four times.[2] Their next scheduled matchup will be sometime during the 2017 NFL season at Heinz Field.

Perhaps the most notable matchup since realignment came in 2008, when the two met in Nashville in a game that determined home-field advantage in the AFC playoffs and a possible preview of the AFC Championship Game. LenDale White and Keith Bulluck stepped on a Terrible Towel after the Titans's 31–14 victory. Pittsburgh's Larry Foote responded, "They deserved to do that, they whooped us, they deserve to celebrate and, hopefully, we'll see them again."[6] While Hines Ward said, "T. J. Houshmandzadeh did kind of the same thing and you see where they went."[6] Former Steelers head coach Bill Cowher, by this point working for CBS as an analyst on The NFL Today, mentioned on The NFL Today (while clearly showing bias in favor of his former team) that such antics can come back to haunt teams.[7] Tennessee proceeded to lose eight consecutive games, including their playoff game against the Ravens and their '09 Week 1 game against the Steelers, capped off by a 59-0 blowout to the New England Patriots, the Titans worst loss ever.

The Steelers edged the Titans 13-10 to open the 2009 season and won again 38-17 in 2010. In 2012 Matt Hasselbeck led the Titans to a close 26-23 win, and in 2013 Jake Locker led a 16-9 win over the Steelers. In 2014 the Steelers rallied from down 24-13 to win 27-24.

Game is notable for Keith Bulluck and LenDale White stomping on a Terrible Towel late in the game after the Titans secured victory and home-field advantage in the playoffs. It would be the Steelers last loss before winning Super Bowl XLIII, while the Titans wouldn't win another game until Week 7 of the following season, with many Titans fans believing that the losing streak started because of the so-called "Terrible Curse".